Clinical UM Guideline


Subject:  Hospital Beds and Accessories
Guideline #:  CG-DME-15Current Effective Date:  10/14/2014
Status:ReviewedLast Review Date:  08/14/2014

Description

This document addresses hospital beds, a specialty bed used primarily in the treatment of individuals with an illness or injury. Hospital bed accessories are durable medical equipment items used in conjunction with a hospital bed.

Note: Please see the following related document for additional information:

Clinical Indications

Hospital Beds

Medically Necessary: 

A fixed height hospital bed is considered medically necessary if one or more of the following criteria are met:

  1. The individual has a medical condition that requires positioning of the body in ways not feasible with an ordinary bed to alleviate pain, prevent contractures, promote good body alignment or avoid respiratory infections.
  2. The individual requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed.
  3. The individual requires special attachments, such as traction equipment, that can only be attached to a hospital bed.

A variable height hospital bed is considered medically necessary if the individual meets one or more of the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair, or standing position. This includes, but is not limited to:

A semi-electric hospital bed is considered medically necessary if the individual meets one or more of the criteria for a fixed height bed and requires frequent changes in body position or has an immediate need for a change in body position.

A heavy-duty, extra-wide hospital bed is considered medically necessary if the individual meets one or more of the criteria for a fixed height hospital bed and the individual's weight is more than 350 pounds, but does not exceed 600 pounds.

An extra heavy-duty hospital bed is considered medically necessary if the individual meets one or more of the criteria for a hospital bed and the individual's weight exceeds 600 pounds.

An enclosed crib or enclosed bed is considered medically necessary for individuals with seizures, disorientation, vertigo, and neurological disorders, where the individual needs to be restrained to bed. Clinical documentation must be provided that states less invasive strategies (i.e., bed rails, bed rail protectors, or environmental modifications) have been tried and have not been successful.

A request for a hospital grade, pediatric crib will be reviewed for medical necessity on an individual basis.

Not Medically Necessary:

If the above criteria are not met, the hospital bed will be considered not medically necessary.

A total electric hospital bed is considered not medically necessary. The height adjustment feature is considered to be a convenience feature.

Ordinary (Non-Hospital) beds are considered not medically necessary. An ordinary bed does not meet the definition of durable medical equipment as it is not primarily medical in nature and is not primarily used in the treatment of a disease or injury.

Power or manual lounge beds are considered not medically necessary since they are not primarily medical in nature and are considered to be a comfort or convenience item.

 

Bed Accessories

Medically Necessary:

Trapeze equipment is considered medically necessary if the individual is confined to bed and needs this device to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or out of bed. Heavy duty trapeze equipment is considered medically necessary if the individual meets the criteria for regular trapeze equipment and weighs more than 250 pounds.

A bed cradle is considered medically necessary when it is necessary to prevent contact with the bed coverings. This includes, but is not limited to individuals with burns, decubitus or diabetic ulcers, or gouty arthritis.

Side rails are considered medically necessary when they are required by the individual's condition and they are an integral part of, or an accessory to, a hospital bed.

If an individual's condition requires a replacement innerspring mattress or foam rubber mattress it will be considered medically necessary for an individual-owned hospital bed.

Not Medically Necessary:

The following bed accessories are considered not medically necessary since they are not primarily medical in nature, are not mainly used in the treatment of a disease or injury and are normally of use to people who do not have a disease or injury:

A frame/canopy for use with a hospital bed and limb restraints is considered not medically necessary since these items are not primarily medical in nature.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS 
 Beds
E0250-E0251Hospital bed, fixed height, with any type side rails
E0255-E0256Hospital bed, variable height, hi-lo, with any type side rails
E0260-E0261Hospital bed, semi-electric (head and foot adjustment), with any type side rails
E0265-E0266Hospital bed, total electric  (head, foot, and height adjustments), with any type side rails
E0290-E0291Hospital bed, fixed height, without side rails
E0292-E0293Hospital bed, variable height, hi-lo, without side rails
E0294-E0295Hospital bed, semi-electric (head and foot adjustment), without side rails
E0296-E0297Hospital bed, total electric, (head, foot and height adjustments), without side rails
E0300Pediatric crib, hospital grade, fully enclosed, with or without top enclosure
E0301-E0304Hospital bed, heavy duty/extra heavy duty (includes codes E0301, E0302, E0303, E0304)
E0328Hospital bed, pediatric, manual, 360 degree side enclosures, top of head board, foot board and side rails up to 24 inches above the spring, includes mattress
E0329Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of head board, foot board and side rails up to 24 inches above spring, includes mattress
  
 Accessories
E0271-E0272Mattress
E0273Bed board
E0274Over-bed table
E0280Bed cradle, any type
E0305Bed side rails, half-length
E0310Bed side rails, full-length
E0315Bed accessory: board, table or support device, any type
E0316Safety enclosure frame/canopy for use with hospital bed, any type
E0910Trapeze bars, also known as Patient Helper, attached to bed, with grab bar
E0911Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses
  
Discussion/General Information

Descriptions

A fixed height hospital bed is one with manual head and leg elevation adjustments but no height adjustment.

A variable height hospital bed is one with manual height adjustment and with manual head and leg elevation adjustments.

A semi-electric bed is one with manual height adjustment and with electric head and leg elevation adjustments.

A total electric bed is one with electric height adjustment and with electric head and leg elevation adjustments.

An ordinary bed is one that is typically sold as furniture. It consists of a frame, box springs and mattress. It is a fixed height and has no head or leg elevation adjustments. It is normally for use in the absence of illness or injury.

Power or manual lounge beds, like other ordinary beds, are typically sold as furniture and are not considered durable medical equipment as they are used in the absence of illness or injury. The following are examples of lounge beds:

The U.S. Food and Drug Administration (FDA) in 2005 determined that the Vail Enclosure Bed poses a significant public health risk because individuals can become entrapped and suffocate, resulting in severe neurological damage or death. Vail Products, Inc of Toledo, Ohio, has permanently ceased manufacture, sale and distribution of all Vail enclosed bed systems.

This Clinical UM Guideline is based on Centers for Medicare and Medicaid Services (CMS) criteria.

References

Peer Reviewed Publications:

  1. Hampton S. Can electric beds aid pressure sore prevention in hospitals? Br J Nurs. 1998; 7(17):1010-1017.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services. National Coverage Determination. Available at: http://www.cms.gov/mcd/indexes.asp?clickon=index. Accessed on June 16, 2014.
    • Durable Medical Equipment Reference List. NCD #280.1. Effective May 5, 2005.
    • Hospital Beds. NCD #280.7. This is a longstanding national coverage determination. The effective date of this version has not been posted.
  2. Electronic Data Systems Corp. Jurisdiction D. Local Coverage Determination for Hospital Beds and Accessories (L11572). Revised 8/01/2013. Available at: http://www.cms.gov/mcd/index_local_alpha.asp?from=alphalmrp&letter=A. Accessed on June 16, 2014.
  3. NHIC. Jurisdiction A. Local Coverage Determination for Hospital Beds and Accessories (L5049). Revised 8/01/2013. Available at: http://www.cms.gov/mcd/index_local_alpha.asp?from=alphalmrp&letter=A. Accessed on June 16, 2014.
  4. U.S. Food and Drug Administration (FDA), Center for Devices and Radiological Health (CDRH). Medical Devices. Hospital beds. Available at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/HospitalBeds/default.htm. Accessed on June 16, 2014.
Index

Hospital Beds and Accessories

History
StatusDateAction
Reviewed08/14/2014Medical Policy & Technology Assessment Committee (MPTAC) review. Description and Websites updated.
Reviewed08/08/2013MPTAC review. Websites and References updated.
 01/01/2013Updated Coding section with 01/01/2013 HCPCS descriptor change.
Reviewed08/09/2012MPTAC review. Websites and References updated.
Reviewed08/18/2011MPTAC review. Websites and References updated.
Reviewed08/19/2010MPTAC review. Websites and References updated.
Revised08/27/2009MPTAC review.
Removed not medically necessary statement addressing the Vail enclosure bed. Removed place of service. References updated.
Reviewed08/28/2008MPTAC review. References updated.
 01/01/2008Updated coding section with 01/01/2008 HCPCS changes.
Revised08/23/2007MPTAC review. Addition of medically necessary statement for enclosure beds. References and coding updated.
Revised12/07/2006MPTAC review. Enclosure beds moved from medically necessary to not medically necessary. Added medically necessary language addressing heavy duty trapeze equipment. References and coding updated.
New12/01/2005MPTAC initial guideline development.
Pre-Merger Organizations

Last Review 
Date

Document 
Number

Title

Anthem, Inc.

 

 No Document
Anthem CO/NV

 

DME.211Hospital Beds and Accessories
Anthem MW

04/08/2005

DME.004Hospital Beds & Other Bed Accessories
Anthem ME

 

Benefit DetailHospital Bed
nthem CT

10/01/2004

DME Coverage Criteria Guideline, Section DHospital Beds and Accessories
WellPoint Health Networks, Inc.  No Document